Team educates staff, ensures compliance

Hospital receives award for significant improvement

Having a dedicated team ensure compliance with the core measures has resulted in significant improvement in patient care quality at Cheyenne (WY) Regional Medical Center.

The hospital was one of only five Wyoming hospitals to receive a 2006 Quality Achievement Award, the highest award given by Mountain Pacific Quality Health to hospitals that show a high level of compliance or significant improvement on 14 of the 22 quality measures established by the Centers for Medicare & Medicaid Services (CMS) and the Joint Commission on Accreditation of Healthcare Organizations (JCAHO).

To qualify for the award, a hospital must demonstrate a 20% decrease in failure rate on 14 of the 22 indicators or maintain a 90% or higher performance rate for at least six consecutive months on the indicator, or achieve a combination of the two options. Cheyenne Regional Medical Center met the criteria for the combination of the options.

At Cheyenne Regional Medical Center, dedicated staff follow the hospital's compliance with the core measures quality indicators.

Christine Kercher, RN, core measures case manager, follows the patients with heart failure and pneumonia. Marlene Griffith, RD, the medical center's cardiovascular clinical data analyst, works to ensure compliance on the myocardial infarction (MI) core measures.

Until the dedicated team was established in 2005, all case managers at the hospital were responsible for the core measures.

Kercher and Griffith operate independently and have different ways of gathering data and monitoring compliance, but their common goal is to make sure that all patients eligible for the core measures receive the recommended treatment unless it's contraindicated.

The core measures team works to create awareness of the core measures and their importance throughout the hospital and works with clinicians to make sure they are compliant with the quality initiative.

Kercher meets every month with the emergency department nurse managers and the head physicians and provides a list of all of the patients who fall out of the core measures.

"We've been having these meetings for about nine months, and it's been very beneficial. It's not often that we have a pneumonia patient who is admitted from the emergency department without having received the initial dose of antibiotics," she says.

The meetings give the emergency department physician the opportunity to say that the focus was not on pneumonia but was on another diagnosis, Kercher says.

When antibiotics were ordered but not given in the emergency department, the nurse manager talks with the staff nurse and reinforces the importance of giving the antibiotic in a timely manner.

When the lapse occurs on the nursing unit, Kercher contacts the nurse manager and talks with the staff nurse to reinforce that the antibiotic needs to be given.

"We try to keep everybody abreast of what is going on," she says.

Reasons for improvement

Griffith cites three factors in the hospital's improvement on the AMI measures: creating an awareness of the core measures among the entire treatment team, starting with emergency personnel; developing an action plan to move patients from the emergency department to the catheterization lab as quickly as possible, and timely reporting and reinforcement of progress.

Griffith started providing data to the heart center's multidisciplinary team in 1999 when the cardiologists initiated a study to track the outcomes of what ultimately became the core measures. She continues to bring core measures data to the multidisciplinary team.

"Early on, our baseline data demonstrated opportunities to improve outcomes for AMI patients. We've communicated core measures information for several years," she says.

Griffith collects data concurrently and makes monthly reports to the multidisciplinary team and the cardiology staff and quarterly reports for the telemetry staff and the emergency department nurse managers. She posts graphs demonstrating the progress on compliance with the core measures in the emergency department, the catheterization lab, and on the telemetry unit.

"Everybody knows where we are at all times," Griffith says.

"Chart reviews are performed whenever a case is an outlier for door-to-open-artery in more than 90 minutes. The review assists the team in pinpointing where we can improve," she says.

Recently, the hospital has added representatives from the local emergency medical service and the community ambulance service to the heart attack team.

The representatives attend the meetings and take an active part, particularly with issues that concern the "pre-door" cases, patients with heart attacks who are transported to the hospital.

This year, the community representatives assisted in writing an AMI algorithm and getting it approved by the agency that regulates emergency medical personnel.

Now emergency personnel can give heart attack patients certain drugs, such as aspirin and beta-blockers in the field.

"It's been very helpful when they can give aspirin and beta-blockers when appropriate under the guidance of their algorithm and they document it for us," Griffith says.

Kercher screens all of the new admissions every day, looking for indications that the patients have a diagnosis of heart failure or pneumonia.

When a patient has a condition that is included in the core measures, she puts a fluorescent green sheet into the patient record to alert the treatment team. The sheet has a check-off list of all the indicators for that particular condition and a place where Kercher can write reminders for documentation.

She attends the daily meeting of all the case managers, representatives from quality improvement, infection control, wound care, diabetes, and other hospital departments.

"We go over who they have identified as potentially having heart failure or pneumonia and compare them to the patients I have identified," Kercher says.

When patients are admitted to a surgical or neurological floor with a secondary diagnosis of pneumonia or heart failure, the case managers alert Kercher. They also let her know when they are treating a patient who has a history of heart failure or pneumonia, even if that is not a reason for hospitalization.

"We communicate by e-mail and in person. I'm in continuous contact with the case managers so they can alert me as to a patient to follow up on. The system works well. We all communicate with each other to make sure that we identify every patient who falls under the core measures," says Kercher.

She visits every patient with a diagnosis of heart failure or pneumonia and makes sure they are aware of what they need to do after discharge to manage their condition.

As Kercher talks with patients, she reminds them of the importance of filling their prescriptions after discharge and notifies the case manager or social worker if the patient might need financial assistance with his or her medication.

"Some of the patients have been living with congestive heart failure a long time. I urge them to contact their doctors if they have a question about their condition so they can avoid rehospitalization," she says.

When another staff member has not completed the smoking cessation initiative, Kercher does it.

Kercher has worked with the hospital's physicians to change the discharge instructions for heart failure patients to include ACE inhibitors and beta-blockers and a space to document contraindications if the medications are not prescribed. "I've worked with the physicians to make sure the medications are prescribed and, if they are not, that there is documentation to support their decision," she says.

Griffith collects data concurrently, reviewing the ICU and telemetry census reports every day.

"By reviewing the charts, I pick up on patients who don't come through the emergency department, such as elderly people who present with nontraditional symptoms but we find out after admission that they had a heart attack," she says.

The hospital's case managers alert Griffith when a patient with a diagnosis of AMI is admitted to a medical floor.

"Everybody is tuned into the core measures, and they let me know if they have a patient whose care falls under the core measures," she says.

She has worked with the multidisciplinary team to create a discharge instruction form, slated for implementation in late 2006, that includes the AMI core measures and discharge indicators.